AHIA Claims Leakage & Fraud Forum HICAPS - Drilling Down Keith Joyce Benefits Risk Manager November 2010 Medibank Private

Reports Backdate Alerts: Recover overpayments where transactions are backdated Body Part alert: Where item number is invalid in relation to a specific body part Claims Alert: A number of alerts to surface claims patterns – to investigate further

Reports - cont Crown alert: Claims to teeth that previously crowned DOS alert: Where DOS changed to enable benefit payout Endo alert: Where D415 & D417 on same tooth i.e. >1 Fill alert: Multiple restorations same tooth - consecutive visits

Reports cont Limit surf: Potential where services claimed for patient that did not receive service Mbr travel: Claims same day, same member, different provider Multi Mod: i.e. Providers co-located – cross refer

Reports cont No tooth alert: Self explanatory Outlier by item & group: item level stats where services are x% above peers Prov Stats: Provider outliers Prov switch: Where prov no. changed to enable payment

Reports cont Prov travel: Claims same provider, same day, different location Rule alert: Claims that are mutually exclusive Run totals: Summary stats for reporting period Upcodes: Claim, then cancelled, claimed higher benefit

Conclusion ? Questions